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Prostate Focused Ultrasound

Therapy 2
Jean-Yves Chapelon, Olivier Rouvière,
Sébastien Crouzet, and Albert Gelet

The tremendous progress in engineering and computing power coupled
with ultrasound transducer technology and imaging modalities over the
past 20 years have encouraged a revival of clinical interest in ultrasound
therapy, mainly in High-Intensity Focused Ultrasound (HIFU). So far, the
most extensive results from HIFU obtained in urology involve transrectal
prostate ablation, which appears to be an effective therapeutic alternative
for patients with malignant prostate tumors. Prostate cancer (PCa) is one
of the most frequently diagnosed cancers in men. Several treatment options
with different therapeutic approaches exist, including HIFU for localized
PCa that has been in use for over 15 years. Since the early 2000s, two
systems have been marketed for this application, and other devices are
currently in clinical trials. HIFU treatment can be used either alone or in
combination with (before- or after-) external beam radiotherapy (EBRT)
(before or after HIFU) and can be repeated multiple times. HIFU treat-
ment is performed under real-time monitoring with ultrasound or guided
by MRI. Two indications are validated today: Primary care treatment and
EBRT failure. The results of HIFU for primary care treatment are similar
to standard conformal EBRT, even though no randomized comparative
studies have been performed and no 10-year follow up data is yet available

J.-Y. Chapelon (*)

INSERM, U1032, Lyon F-69003, France
Laboratory of Therapeutic Applications of Ultrasound,
Université Lyon 1, Lyon, France
O. Rouvière S. Crouzet • A. Gelet
INSERM, U1032, Lyon F-69003, France INSERM, U1032, Lyon F-69003, France
Laboratory of Therapeutic Applications of Ultrasound, Laboratory of Therapeutic Applications of Ultrasound,
Université Lyon 1, Lyon, France Université Lyon 1, Lyon, France
Department of Radiology, Hospices Civils de Lyon, Department of Urology, Hospices Civils de Lyon,
Edouard Herriot Hospital, Lyon, France Edouard Herriot Hospital, Lyon, France

© Springer International Publishing Switzerland 2016 21

J.-M. Escoffre, A. Bouakaz (eds.), Therapeutic Ultrasound, Advances in Experimental
Medicine and Biology, Vol. 880, DOI 10.1007/978-3-319-22536-4_2
22 J.-Y. Chapelon et al.

for HIFU. Salvage HIFU after EBRT failure is increasing with oncological
outcomes, similar to those achieved with surgery but with the advantage of
fewer adverse effects. HIFU is an evolving technology perfectly adapted
for focal treatment. Thus, HIFU focal therapy is another pathway that
must be explored when considering the accuracy and reliability for PCa
mapping techniques. HIFU would be particularly suited for such a therapy
since it is clear that HIFU outcomes and toxicity are relative to the volume
of prostate treated.

HIFU • Prostate cancer

2.1 Introduction published by Klotz et al. (2010): At 10 years

38 % of patients had left active surveillance and
PCa (Prostate Cancer) is the most common male had been treated with surgery or external beam
cancer after the age of 60. The American Cancer radiation; 50 % of them were biological failures
Society’s estimates for PCa in the United States at 5 years. Treatment of PCa by High Intensity
for 2014 are that 233,000 new cases of PCa will Focused Ultrasound (HIFU) is a new therapeutic
be diagnosed and 29,480 men will die of PCa.1 In modality in use in clinics since 2000 for first-line
the absence of large randomized trials, it is often treatment of PCa (Crouzet et al. 2010b) and for
difficult to define the therapeutic strategy for patients with local recurrence after external
clinically localized or locally advanced PCa dis- radiotherapy (Murat et al. 2009). HIFU treatment
ease detected in elderly patients. The latest results is a potential treatment option whose place
of the Scandinavian randomized study compar- remains to be defined. The tremendous progress
ing radical surgery versus watchful waiting con- in engineering and sciences coupled with ultra-
cluded that there was no benefit from radical sound transducer technology and imaging modal-
prostatectomy in terms of metastasis-free sur- ities during the past 20 years, together with better
vival and disease-specific survival in patients understanding of PCa natural history, offer new
over 65 years old (Bill-Axelson et al. 2008). opportunities to change the terms of support with
Note, however, that in this study patients were a wider area devoted to the use of HIFU.2
not subjected to prostate specific antigen (PSA)
The three main strategies for PCa treatment of 2.2 History and Principle of PCa
elderly patients are conformal radiotherapy, Treatment by HIFU
brachytherapy and active watchful waiting.
Recent studies have demonstrated that local con- HIFU is a non-ionizing and non-surgical physical
trol of the disease would be obtained in only therapy that produces biological effects by ther-
68 % of patients after treatment with external mal and mechanical means. Heating tissue dena-
conformal radiotherapy. For patients with one tures proteins and leads to cell death, regardless of
positive control biopsy, the biochemical control whether they are normal or abnormal, whereas
at 10 years is 5 % and the metastasis-free survival mechanical effects disrupt cells by the collapse of
rate is 69 % (Zelefsky et al. 2008). The results of
long-term active surveillance have recently been 2
The authors published some materials of this book chap-
ter in 2012 in Chapter 6 of “Management of Prostate, A
h t t p : / / w w w. c a n c e r. o rg / c a n c e r / p r o s t a t e c a n c e r / Multidisciplinary Approach”. Springer, Bolla, Michel,
detailedguide/prostate-cancer-key-statistics van Poppel, Hendrik (Eds.), 2012, pp.191–212.
2 Prostate Focused Ultrasound Therapy 23

microbubbles generated by cavitation. In most patients in 1999 (Gelet et al. 1996, 1999). The
applications, spherically shaped power transduc- main results of these studies were that histological
ers are used to focus the ultrasound energy onto a analysis of prostate biopsies performed 48 h after
target point deep within the body. This results in HIFU treatment showed significant inflammation
thermal tissue coagulation necrosis, cavitation and lesions of coagulation necrosis, which hamper
and heat shock. Each sonication heats only a the identification of viable cancer cells. At 3
small focal target, creating an elementary lesion months, prostate biopsies were the seat of intense
with extreme precision and accuracy. well-circumscribed fibrous reactions, making it
Subsequently, multiple sonications are necessary possible to easily identify any residual cancer
to create, side-by-side and layer after layer, a vol- cells.
ume of lesions covering the entire target volume The main advantages of HIFU treatment are:
to be ablated. The main sonication parameters are
acoustic intensity, duration of exposure, on/off – The lack of induction of apoptosis avoiding
ratio, the distance between 2 elementary lesions late complications of treatment. No late rectal
and the displacement path when multiple lesions or bladder toxicity has been reported.
are made. – A PSA nadir obtained in the first 8 weeks fol-
The first description of HIFU was made in lowing tissue damage immediately allows one
1942 and the ability to destroy tissue established to conclude that treatment has been effective.
in 1944 (Lynn et al. 1942; Lynn and Putnam PSA nadir is also an independent predictor of
1944). However, the general technology remained treatment success (Beerlage et al. 1999;
in an experimental setting for over 50 years, and Kennedy et al. 2003; Chaussy et al. 2005).
only recently has this technology been employed – A lack of cumulative effect with the possibil-
for approved clinical applications. Indeed, the tre- ity of repeating treatment.
mendous progress in engineering and sciences
coupled with ultrasound transducer technology By combining accurate control of the position
and imaging modalities during the past 20 years of the transducer within the rectum and active
has encouraged a revival of clinical interest in cooling of the rectal mucosa, the risk of rectal
HIFU. It is currently used to non-invasively treat a injury is minimized. This technique offers the
variety of clinical conditions including: advantage of a transrectal treatment to ablate
Symptomatic uterine fibroids, tumors in the pros- prostate tissue while sparing the rectum itself
tate, breast, liver low back pain and brain disor- (Gelet et al. 1999).
ders, such as essential tremor, Parkinson’s disease
and epilepsy.
The first experiments on the prostate were
made in the early 90s. It was first demonstrated 2.3 HIFU Devices Dedicated
with the adenocarcinoma of a prostate experimen- to PCa Treatment
tally implanted in rats (R 3327 AT2 Dunning
tumor) that HIFU could be used to ablate tumors Since the early 2000s, two HIFU devices have
and cure cancer without causing metastases been commercially available for the treatment
(Chapelon et al. 1992). It was next established that of PCa: Ablatherm® (EDAP TMS, Vaulx-en-
it was possible to induce regions of irreversible Velin, France) and Sonablate® (SonaCare
coagulation necrosis in canine prostates without Medical LLC, Charlotte, NC, USA). Both
damaging the rectal wall (Gelet et al. 1993b). The devices operate transrectally under ultrasound
first treatments in men were performed in 1992 on guidance and are approved for commercial dis-
benign prostate hyperplasia (Madersbacher et al. tribution in the European Union, Canada, South
1993; Gelet et al. 1993a, b). The results of a pilot Korea, Japan and Russia. The most important
study on PCa treatments were published in 1996 difference in the two devices is in their patient
and the preliminary results from the first 50 positioning.
24 J.-Y. Chapelon et al.

2.3.1 Ablatherm® with Ultrasound post brachytherapy. The treatment plan involves
Integrated Imaging setting up the probes to target the thermal lesion
within the prostate. The operator defines the
The Ablatherm II® (EDAP TMS, Vaulx-en-Velin, boundaries of the target area using the US scan-
France) integrates both the imaging transducer ner. The Ablatherm II® is then switched to treat-
(7.5 MHz) and the therapeutic transducer ment mode and the computer-driven module
(3 MHz) in a single endorectal probe focused at induces lesions using the HIFU transducer. To
40 mm. The probe is covered by a latex condom treat the entire target area, several sonications are
filled with a coupling and refrigerant liquid to made side-by-side, first moving the head follow-
thermally protect the rectal wall. The probe is ing the transverse plane (right-left), and then
mounted on a computer-controlled motorized following the longitudinal plane (perpendicularly
holder that allows movements in three spatial to the transverse plane). The lesion height may be
directions. The Ablatherm II® requires a special adjusted between 19 and 24 mm to match the size
bed with the patient in a lateral position (Fig. 2.1). of the target area. The device offers real-time
The lateral position of the treatment allows ultrasonic monitoring of the treatment because
gas bubbles produced in the coupling liquid dur- HIFU-induced lesions are visible using standard
ing heating of the prostate to rise by buoyancy to ultrasound as hyper-echoic areas, but their extent
a position outside the field of view of the imaging is not always accurately defined. However, at the
probe, and therefore of the therapy transducer. end of the procedure contrast-enhanced ultra-
The Ablatherm II® software includes four treat- sound with Sonovue® (Bracco Imaging,
ment protocols with specially designed treatment Switzerland) may be implemented to validate
parameters depending on the clinical use: Primary treated volumes and to define areas for treatment
care (standard), retreatment, radiation failure and completion.

Fig. 2.1 Ablatherm® integrated imaging device

2 Prostate Focused Ultrasound Therapy 25

2.3.2 Sonoblate 500 anterior-posterior dimensions of the prostate),

beginning with the anterior portion of the pros-
The Sonablate 500® (SonaCare Medical LLC, tate and moving to the posterior part by changing
Charlotte, NC, USA) is based on a console, a the focal length during the procedure. The choice
fully integrated probe (Fig. 2.2) and a module for of the focal length depends on the size of the
degassing and circulating chilled water in the prostate. The maximum prostate size that can be
probe tip. The console consists of a portable sys- treated is 40 mm AP dimension. The latest ver-
tem with a display monitor, an articulating arm sion of the device uses a pulse echo back-scattered
with reliable probe holding capabilities and a ultrasound (RF signals) -processing algorithm
stepper motor with 3-axes of precise movement. called TCMTM (Tissue Change Monitoring) to
The transrectal probe uses double-sided and check in real-time whether the treatment was suf-
dual-mode transducers for imaging (6.3 MHz) ficient. A pulse echo RF signal is sent to the treat-
and treatment (4 MHz). The double-sided trans- ment site prior to delivery of HIFU energy, and
ducer is available with two focal lengths (30– then the second signal is sent post HIFU delivery
40 mm) that move robotically to follow the to the same treatment site. The TCMTM algorithm,
precise treatment plan devised by the physician. in real time, calculates and quantifies the tissue
The size of an elementary thermal lesion is change that takes place in the treatment site and
10–12 mm long and 3 mm in diameter. The treat- displays the degree of HIFU lesion completeness
ment is performed in the supine position. The on the screen. This feedback allows the physician
system uses a treatment protocol allowing adjust- to re-treat the sites that were not treated opti-
able power settings for customizable treatment mally. For more details on the Sonablate 500® see
by the physician. The treatment is carried out in Chap. 6 of “Therapeutic Ultrasound: Mechanisms
two or three consecutive layers (based on to Applications” (Tavakkoli and Sanghvi 2011).

Fig. 2.2 Sonoblate® device

26 J.-Y. Chapelon et al.

2.3.3 Focal One can be used to modify in real-time the shape and
size of the treatment area; this was not possible
A new device, FocalOne® (EDAP TMS, Vaulx- with the Ablatherm II®. Finally, in post-treatment
en-Velin, France), has recently been developed sessions, contrast-enhanced Ultrasound with
by EDAP to deliver HIFU treatment by combin- Sonovue® is used to validate treated areas and to
ing all the latest technologies in imaging and define the areas for treatment completion. In the
treatment for an ideal PCa therapy: Accurate and days following the procedure, review of treat-
MRUS-based fusion imaging guidance, a non- ment images is available for comparison with
invasive surgical approach, precise and efficient MR follow-up images.
therapeutic energy and end-of-treatment valida- A new probe based on the technology of
tion imaging. “dynamic focusing” (beam steering) has been
In contrast to Ablatherm II®, the FocalOne® developed to deliver localized thermal therapy to
does not use a special bed and consists of a single the areas of the prostate gland via the transrectal
module (Fig. 2.3). The treatment sequence now approach. The probe has the same ergonomic
includes a pre-treatment step in which MR pros- design and the same ultrasound imaging trans-
tate images of the patient are imported from ducer as that of the Ablatherm II® (Fig. 2.3). The
PACS or CD and elastic fusion is automatically HIFU transducer consists of an annular array
performed to match the 3D contours of the pros- with 16 individual concentric rings. All of the
tate on the MRI and ultrasound images. For the rings have the same surface area and are fed
pre-treatment step, the 3D MR target is automati- through their own amplifier channel (16 chan-
cally displayed on live ultrasound, and the soft- nels). The geometric focal point of the firing head
ware makes it possible to design a precise target is located at 60 mm from the front face, instead of
area with accuracy better than 1 mm. A second 40 mm for that of the Ablatherm II®. The annular
screen displays the conformational treatment array makes it possible to steer the ultrasound
with an ultrasound image of the prostate and the beam at different depths and to adjust the treat-
target area defined in the prostate. The software ment according to the thickness of the prostatic

Fig. 2.3 Focal One® device

2 Prostate Focused Ultrasound Therapy 27

tissues to be treated. In particular, it is possible to always be maintained within the gland, as well
focus the ultrasound beam at a depth other than as large prostates with antero-posterior distances
the natural radius of curvature of the transducer. of up to 35 mm, which corresponds to prostates
The objective is to fit the treated volume as of about 50 cc. This is an improvement over the
closely as possible to the geometry of the pros- fixed focus transducer that could only treat pros-
tate, approaching a model of lesions formed tates with a maximum antero-posterior distance
“point by point” with short sub-sonications per- of 26 mm, which corresponded to prostates with
formed at different depths. For this, a phase shift a maximum of 30 cc. Finally, it is possible to
is performed electronically on each ring to steer shorten the duration of treatment for a given
the HIFU beam along the axis of penetration, treated volume. In fact, the shots fired at shallow
allowing enough depth to be reached to treat depth will be associated with reduced firing
large prostates. power. Rest periods, with the aim of limiting the
The advantage of this new probe is that it temperature rise in the rectal wall, could there-
allows for a correction of the major disadvan- fore be shortened.
tages associated with the use of a fixed focus
transducer. The 16 annular elements activated by
a multichannel generator are used to split each 2.3.4 MRgFUS Devices
sonication into sequences of one-second sub-
sonications. Each sub-sonication ablates an Magnetic resonance guided focused ultrasound
ellipsoidal volume of 5 mm in height. The lesion surgery (MRgFUS) was recently presented as a
consists of a small region of coagulation necro- method for ablation with focused ultrasound
sis with reduced cavitation effects and concen- under magnetic resonance imaging guidance.
trated thermal diffusion. The device makes it This approach has the advantage of improved tar-
possible to add dynamic focusing sub-sonica- geting and real-time temperature monitoring. To
tions along the axis of penetration of the ultra- date, two different approaches have been used for
sound beam. It is therefore possible to obtain MRgFUS of the prostate: One with a transrectal
small necrotic lesions of 5 mm long with a shot probe compatible with the ExAblate® system
of 1 s. Although the damage obtained with a sin- (InSightec, Haifa, Israel) under a 1.5 T GE MRI,
gle shot is small, large treatment zones can be and another with a MRI-compatible ultrasound
obtained up to 40 mm in length, by adding 8 suc- applicator to deliver controlled thermal therapy
cessive sub-sonications of 5 mm each. The fact to the regions of the prostate gland via a trans-
that the height of the lesions can be varied urethral approach (Profound Medical Inc.,
between 5 and 40 mm allows for better matching Toronto, Canada). The potential of both technol-
of the treated area to the morphology of the pros- ogies is currently being demonstrated in Phase I
tate, as the focal point being always inside the clinical trials, but only a few studies have been
prostate. The thermal dose delivered to the pros- conducted in therapy of PCa with human patients
tate is theoretically homogeneous, with fewer (Zini et al. 2012; Chopra et al. 2012), and most of
thermal diffusion phenomena, laterally towards the currently available literature on MRgFUS for
the neurovascular bundles and vertically toward prostate uses a canine model for research
the striated sphincter. The anatomical distribu- (Siddiqui et al. 2010; Chopra et al. 2009).
tion and homogeneous thermal dose throughout
the prostate gland is expected to achieve better
oncological results regardless of the size of the 2.4 Long-Term Outcomes
prostate. Furthermore, the absence of thermal of HIFU in PCa Treatment
diffusion should provide a significant reduction
in side effects, such as incontinence and impo- This section gives an extensive review of clinical
tence. This new probe can be used to treat many, outcomes in all uses of HIFU technology for
very small prostates with a focal point that will treatment of localized PCa.
28 J.-Y. Chapelon et al.

2.4.1 HIFU as Primary Care Crouzet et al. 2011). In our institution, we have
Treatment recently reviewed the results of 880 patients. The
mean age was 70 years old. Stratification accord-
The recommendations and updated guidelines ing to d’Amico’s risk group was low, intermedi-
on the use of HIFU for PCa as a primary treat- ate and high in 36 %, 48 % and 16 %, respectively.
ment concern patients with localized PCa (clini- Median follow-up was 41 months. Median PSA
cal T1-T2 stage Nx/0 M0 PCa) for whom radical nadir was 0.1 ng/mL. The overall and cancer-
prostatectomies are not an option for one of the specific survival rates at 7 years were 90 and
following reasons: Age >70 years old, life expec- 98 %, respectively. The metastasis-free survival
tancy ≤10 years, major co-morbidities which rate at 7 years was 96 %. The 5- and 7-year
preclude surgery or the simple refusal on the part disease-free survival rates were 75–62 %,
of the patient to undergo surgery (Rebillard et al. 59–50 % and 45–39 % for low, intermediate and
2003; AURO 2009). Among the publications on high risk patients, respectively (p = 0.0001)
HIFU as a primary therapy for PCa, 16 studies (Crouzet et al. 2010a, b, c). Recent articles pub-
report on a series of at least 50 patients (Uchida lished in 2013 from three European urology
et al. 2006a, b, 2009; Crouzet et al. 2010a, b, c; departments confirm the long-term efficacy of
Lee et al. 2007; Poissonier et al. 2007; Ahmed HIFU treatment (Crouzet et al. 2014; Thüroff and
et al. 2009; Blana et al. 2008a, b, 2009; Mearini Chaussy 2013; Ganzer et al. 2013).
et al. 2009; Misrai et al. 2008; Ganzer et al. In a study from a prospective database, Shoji
2008; Turoff et al. 2003; Chaussy and Thuroff et al. included 326 patients who filled in self-
2001; Gelet et al. 2000), while the others report administered questionnaires on urinary function,
on fewer patients (Ficarra et al. 2006; QOL and sexual assessment (Shoji et al. 2010).
Challacombe et al. 2009; Maestroni et al. 2008; The FACT G, FACT-prostate and IIEF 5 were
Koch et al. 2007). Follow-up varies significantly used. Maximum flow rate and residual urine vol-
between series (range: 6 months to 6.4 years). In ume were significantly impaired at 6 months
most cases, the PSA nadir was reached 3–4 (p = 0.010) after HIFU, even though they returned
months after treatment by HIFU, and to baseline values at 12 or 24 months after
was = 0.05 ng/mL in 55–91 % of the cases. Many HIFU. The total FACT-G score significantly
studies have demonstrated that the PSA nadir improved at 24 months (p = 0.027) after HIFU. At
was a significant predictor of HIFU failure. 6, 12 and 24 months after HIFU, 52 %, 63 % and
Patients with a PSA nadir over 0.5 ng/mL must 78 %, respectively, of the patients who had not
be carefully monitored (Lee et al. 2007; Ganzer received neoadjuvant hormonal therapy were
et al. 2008). A PSA nadir >0.2 ng/mL after HIFU potent.
has been associated with a four times greater risk In a prospective study, Li et al. compared the
of treatment failure, which is defined as a posi- IIEF score, penile colour Doppler ultrasound,
tive biopsy after HIFU treatment (Uchida et al. penile length and circumference on patients treated
2006a). for PCa with HIFU or cryoablation
The 7-year disease-free survival rate in the (Li et al. 2010). A total of 55 patients in the
longest follow-up multicenter studies was 75 %, HIFU group and 47 in the cryoablation group were
63 % and 62 % for low, intermediate and high- included. At 36 months, cryoablation patients
risk patients, respectively, and the 8-year cancer- experienced a lower erectile function recovery rate
specific survival rate was 99 % (Crouzet et al. compared to HIFU patients (Cryoablation = 46.8 %;
2010a, b, c). Complication rates are low with HIFU = 65.5 %; p = 0.021). No significant
sloughing occurring in 0.3–8.6 %. Impotence decreases in penile length and circumference were
occurs in 20–77 % of patients and bladder outlet found in the two groups (all p-values ≥0.05).
obstruction in 12–22 %. The incontinence rates Finally, HIFU treatment seems to be standardized
reported in a recent study were grade I (4–17.5 %) with similar outcomes between centers (Rebillard
and grade II and III (0–5 %) (Chaussy et al. 2005; et al. 2003).
2 Prostate Focused Ultrasound Therapy 29

2.4.2 Salvage After HIFU Failure Salvage Surgery

Salvage surgery is feasible after HIFU but with HIFU Retreatment higher morbidity than after primary surgery.
One of the potential interests of HIFU, especially Lawrentschuk et al. (2011) reported the results in
compared to radiotherapy, is the fact that treat- 15 men with a rising PSA and biopsy-verified
ment can be repeated. Unlike radiation, there is PCa after HIFU treatment. Perioperative morbid-
no dose limitation and no limited number of ses- ity was limited to one transfusion in a patient
sions. In case of incomplete treatment or treat- with a rectal injury. Pathological extensive peri-
ment failure, HIFU does not result in a therapeutic prostatic fibrosis was found in all patients.
impasse. The re-treatment rate is estimated in the Postoperative PSA value was undetectable in 14
literature to be between 1.2 and 1.47 % (Uchida patients (93.3 %). Six out of 10 patients experi-
et al. 2006a, b, c; Crouzet et al. 2010a, b, c; enced no postoperative incontinence at 12
Thuroff et al. 2003; Blana et al. 2006). Morbidity months, but with uniformly poor erectile func-
related to repeat HIFU treatment for localized tion. Salvage surgery after HIFU is difficult to
PCa has been studied on 223 patients with a re- perform due to fibrotic reaction. In selected
treatment rate of 22 %. While urinary infection, patients with a long life expectancy, only experi-
bladder outlet obstruction and chronic pelvic enced surgeons should perform salvage surgery
pain did not significantly differ after one or more after HIFU.
sessions; a significant increase was observed for
urinary incontinence and impotence in the group,
which required retreatment (Blana et al. 2006). 2.4.3 Salvage HIFU After ERBT
or Brachytherapy External Radiation Therapy
(ERBT) External radiation therapy (ERBT), or brachy-
EBRT is feasible after HIFU. In a retrospective therapy, is used as a curative treatment of local-
study, Pasticier et al. (2010) included patients ized PCa. Several studies have shown that tumor
treated with salvage radiation after HIFU. A total destruction is not complete (Kirkham et al. 2008).
of 100 patients were included with a median fol- Given these tumor recurrences, there is no clear
low-up of 33 months. Mean doses of radiation consensus on selecting optimal therapeutic man-
were 71.9 ± 2.38 Gys. 83 patients underwent radi- agement. Most often a hormonal treatment is
ation treatment only and 17 patients underwent implemented to delay the onset of metastasis.
radio-hormonal treatment. The mean time Recovery techniques exist, including radical
between HIFU and ERBT was 14.9 ± 11.8 months. prostatectomy, cryotherapy and brachytherapy,
Mean PSA before salvage ERBT was 2.1 ± 1.8 ng/ but they are technically difficult and induce sig-
mL and the nadir PSA after ERBT was nificant side effects. The efficacy of HIFU was
0.28 ± 0.76 ng/mL, with 17.4 ± 10.8 months to evaluated as salvage treatment following radio-
reach nadir. The incontinence rate was the same therapy failure to identify pre-operative predic-
both before and 1 year after salvage ERBT. The tive factors of success.
progression-free survival rate was 76.6 % at 5
years, and was 93, 70 and 57.5 % for low, inter- ERBT Failure
mediate and high-risk groups, respectively. The The rate of positive biopsy after External Beam
predicting factors of failure were the PSA nadir Radio Therapy (ERBT) for PCa in the literature is
after salvage ERBT and the time to reach nadir between 25 and 32 % (Borghede et al. 1997;
after ERBT. Recently, similar results were pub- Zelefsky et al. 2001). There appears to be curative
lished by Ripert et al. (2011) which reported the intents for salvage HIFU therapy for patients with
disease free survival rate after HIFU was 3 % at a locally proven recurrence after external-beam
36.5 months (Phoenix criteria) and there was no radiation therapy (patients presenting no metasta-
major EBRT related toxicity at 12 or 24 months. ses) and for patients that are usually treated with
30 J.-Y. Chapelon et al.

androgen deprivation (AD). Local control was similar oncological outcomes. In this context,
achieved with negative biopsies in 73 % of cases, HIFU appears to be an effective curative treatment
with a median PSA nadir of 0.19 ng/mL (Murat option for local recurrence after radiation failure.
et al. 2009). A mean follow-up of 18.1 (3–122)
months was reported, the overall actual 5-year spe- Brachytherapy Failure
cific survival rate being 84 %. The actual 3-year Sylvester et al. (2010) reported a 15-year bio-
progression-free survival (PSA greater than chemical relapse-free survival rate and cause-
nadir + 2 ng/mL, positive biopsy or salvage treat- specific survival following Iodine-125 prostate
ment requirement) was 53, 43 and 25 % for low- brachytherapy in 215 patients: 15-year biochemi-
and intermediate-risk patients, respectively, cal relapse free survival (BRFS) for the entire
according to D’Amico’s risk groups. Disease pro- cohort was 80.4 % and the cancer specific sur-
gression was inversely related to pre-HIFU PSA vival rate was 84 %. There was no significant dif-
and the use of AD during PCa management. In a ference between the low and intermediate risk
recent study, we examined the outcomes of sal- groups. Salvage surgery is a challenging proce-
vage HIFU in 290 consecutive patients (Crouzet dure after Brachytherapy (Heidenreich et al.
et al. 2012). The mean PSA nadir post-HIFU was 2010). A study with the Ablatherm® device is
1.54 ± 3.38 ng/mL (median 0.14). The estimated currently being conducted in Lyon and includes
cancer-specific and metastasis free survival rates 26 patients (mean age 67 years) with MRI and
at 5 and 7 years were 80 % (95 % CI 72.7–88.5 %) biopsy-proven recurrence after brachytherapy
and 79.6 % (95 % CI 73.5–86.2 %), respectively. (non-published data). Nineteen of them under-
In the multivariate analysis three factors were sig- went whole gland ablation and 7 underwent focal
nificantly linked to disease progression. The therapy (hemiablation). The mean follow-up was
increase of the Progression Free Survival Rate 19 months. The mean PSA before HIFU was
(PFSR) with the pre-HIFU PSA level was statisti- 5.02 ± 4.8 ng/mL, (median PSA 0.35 ng/mL).
cally significant (p = 0.0002). Previous AD treat- Nine patients have undetectable PSA with no
ment increased the PFSR by a factor of 1.3 hormonal deprivation treatment, 8 needed hor-
(p = 0.01), and a Gleason score over or equal to 8 monal deprivation treatment for a rising PSA and
increased it by a factor of 1.2 (p = 0.01), compared 9 are recent cases with a very short follow-up.
to a Gleason score of less than or equal to 6. While The complication rate was high in the first 9 cases
the technique offers promising results, it has to be with 3 urinary incontinences (grade 3) and 1 ure-
weighed against the side effects. Since 2002, the throrectal fistula. For these first patients, we used
Ablatherm® device has included specific acoustic the treatment acoustic parameters defined for
parameters for salvage HIFU. The acoustic dose radiation failure. Due to the high rates of rectal
was adapted to the low blood flow inside the gland injury and severe incontinence, new specifically
fibrosis induced by radiation. Concerning inconti- designed treatment parameters for brachytherapy
nence, 54 % of the patients had no incontinence failure were developed with a decrease in the
after salvage HIFU, whereas 25 % had a grade I acoustic dose according to the intense prostate
incontinence (no pads + grade I = 79 %). The risk fibrosis. Since the introduction of these new
of urethrorectal fistulas (URF) was only 0.4 % parameters, no urethrorectal fistula occurred and
with the introduction of a specific treatment algo- no rectal lesion was seen on control MRI, all
rithm designed for radiation failure. The impo- while maintaining same treatment efficacy.
tence rate increased from 36.9 % before salvage
HIFU to 58.7 % after treatment (Berge et al. 2010).
With the Sonablate®, the biochemical survival rate 2.5 Focal Therapy with HIFU
was 71 % at 9 month (Zaracharakis et al. 2008)
and 52 % at 5 years (Uchida et al. 2010). Standard treatment for PCa has long been
Nevertheless, the risk–benefit ratio of salvage “whole-gland” therapy or radiation therapy of the
HIFU compares favourably with those of the other entire prostate. It would be interesting, however,
available techniques and with less morbidity and to destroy only the cancer foci in order to decrease
2 Prostate Focused Ultrasound Therapy 31

the treatment morbidity while maintaining its localization, and the results of US-based tech-
oncologic efficacy. This so-called ‘focal therapy’ niques have been particularly disappointing
can be performed using several techniques: (Rouvière et al. 2007).
Cryotherapy, HIFU, Brachytherapy and Nevertheless, excellent results have recently
Interstitial Laser Therapy, either with or without been published with MRI, especially since
photodynamic therapy (PDT). HIFU might be dynamic contrast-enhanced (DCE) and diffusion-
one of the best techniques for focal therapy weighted (Dw) sequences have been used in
because it is performed under real-time control addition to the classical T2-weighted (T2w)
using ultrasound or MRI. Immediate control of imaging. There is now a large and concordant
the necrotic area boundaries is possible using body of literature showing that this so-called
contrast agents, either with ultrasound or prostate ‘multiparametric MRI’ (mp-MRI) allows
MRI. HIFU can also be repeated if necessary. for good detection of high-grade PCas (Gleason
Finally, several salvage standard curative thera- score ≥7), with an excellent negative predictive
pies are feasible after focal HIFU. value in candidates undergoing radical prostatec-
The first condition for ‘focal therapy’ is to pre- tomy (Girouin et al. 2007; Villers et al. 2006;
cisely determine the size and position of the differ- Turkbey et al. 2010; Bratan et al. 2013), but also
ent tumor foci within the gland before the ablation. in the more challenging population of candidates
Standard biopsy protocols cannot provide an accu- undergoing prostate biopsy (Cheikh et al. 2009;
rate detection of all tumor foci. Transperineal tem- Habchi et al. 2014) (Fig. 2.4).
plate biopsies may increase cancer detection. The detection of anterior tumors, which are
However, the precision of the location within the usually missed by random biopsies, is also
gland of the cancers detected with this method excellent (Lemaitre et al. 2009). A recent study
remains difficult to assess. Additionally, template reported the results of precise radiopathological
biopsy requires general anaesthesia or heavy seda- correlations in 175 patients treated by radical
tion and is associated with increased morbidity, prostatectomy following preoperative mp-MRI
with at least 10 % of urinary retention due to (CLARA-P database). MR detection rates for
oedema and bleeding (Rouviere et al. 2012a). tumors of <0.5 cc, 0.5–2 cc and >2 cc were
Ideally, the simplest way to select patients for respectively 21–29 %, 43–54 % and 67–75 % for
focal therapy would be to use imaging. Imaging Gleason ≤6 cancers, 63 %, 82–88 % and 97 %
could also be used to assess whether the target area for Gleason 7 cancers, and 80 %, 93 % and 100 %
has been correctly destroyed and to detect for local for Gleason ≥8 cancers (Bratan et al. 2013).
recurrences. Nonetheless, its role in focal therapy These results suggest that mp-MRI is an excel-
remains under debate. lent screening tool, with a good negative predic-
tive value for Gleason ≥7 tumors. However, the
detection of Gleason ≤6 tumors remains limited.
2.5.1 The Current Role of Imaging In addition, mp-MRI specificity needs to be
in PCa Focal Therapy improved since up to 40 % of MR abnormalities
are benign (Bratan et al. 2013; Cheikh et al.
In theory, imaging could be used in three different 2009; Habchi et al. 2014; Lemaitre et al. 2009;
fields: To detect and localize PCa within the gland, Rouviere et al. 2012a, b). To improve the charac-
to assess tissue destruction after HIFU ablation terization (benign/malignant) of focal lesions
and to detect post-HIFU cancer recurrence. detected by mp-MRI, it has been suggested that
a five-level Likert score (1, definitely benign; 2, Patient Selection likely benign; 3, indeterminate; 4, likely malig-
and Treatment Planning: nant; 5, definitely malignant) be used. Although
The Need for Better PCa subjective and entirely based on the radiologist’s
Mapping experience, this score has been proved to signifi-
For many years, prostate imaging has yielded cantly stratify the likelihood of malignancy of
suboptimal results in PCa detection and MR lesions. In the CLARA-P database, the per-
32 J.-Y. Chapelon et al.

Fig. 2.4 MRI: a b

Multiparametric MRI
obtained in a 59-year old
patient with a PSA level of
6 ng/mL presenting a
suspicious lesion in the
peripheral zone of the left
mid-gland, with marked
hyposignal on the
T2-weighted imaging (a,
arrow). Apparent Diffusion
Coefficient map (b, arrow)
and early and marked
enhancement on Dynamic
Contrast-Enhanced imaging
(c, arrow). Radical c d
prostatectomy confirmed the
presence of a Gleason 8
(4 + 4) cancer (d)

centage of malignant lesions was 7–26 %, on preliminary studies (Hambrock et al. 2013;
27–41 %, 61–72 % and 97–98 % in MR lesions Niaf et al. 2014).
with a Likert score of 2/5, 3/5, 4/5 and 5/5, Focal ablation also requires a good evaluation
respectively (Bratan et al. 2013). Semi-objective of the tumor volume. Little has been published on
scores based on more precise features have been mp-MRI accuracy in assessing tumor volume.
described recently (Rouviere et al. 2012a, b; Several studies have, however, pointed out that
Barentsz et al. 2012; Puech et al. 2013). mp-MRI had a tendency to underestimate tumor
Particularly, the European Society of Urogenital volume (Cornud et al. 2014; Le Nobin et al.
Radiology (ESUR) endorsed the Prostate 2014). The optimal safety margin to use around
Imaging Reporting and Data System (PIRADS) malignant lesions seen on mp-MRI remains to be
that assigns a score ranging from 3 to 15 based determined.
on T2w, Dw and DCE imaging (Barentsz et al. After radiation therapy, mp-MRI showed
2012). However, it remains unclear whether excellent results in detecting and localizing local
these semi-objective scores perform better than recurrences (Cornud et al. 2014; Le Nobin et al.
the subjective Likert score. Two recent studies 2014; Rouvière et al. 2004; Haider et al. 2008;
have even shown that, paradoxically, the Likert Donati et al. 2013; Roy et al. 2013). Tumor detec-
score yielded better inter-observer agreement tion appears easier than in untreated prostates
than the PIRADS score (Rosenkrantz et al. 2013; because of the favourable contrast between recur-
Vache et al. 2014). Thus, new scores will proba- rent cancer and post-radiation fibrosis on DCE
bly be defined in the future to improve the and Dw imaging (Fig. 2.5).
characterization of MR abnormalities seen at In conclusion, mp-MRI is an interesting tool
mp-MRI. Some authors also used computer- for detecting and localizing Gleason ≥7 PCas.
aided diagnostic systems with interesting results Targeted biopsies of MR abnormalities remain
2 Prostate Focused Ultrasound Therapy 33

a b

Fig. 2.5 Post-EBRT recurrence. MRI obtained in a slightly hypointense on T2-weighted imaging (a, arrow)
66-year old patient with history of external-beam radia- with a marked enhancement on Dynamic Contrast-
tion therapy for a Gleason 6 PCa 5 years earlier. MRI Enhanced imaging (b, arrow). Targeted biopsy confirmed
shows recurrent cancer in the right mid gland appearing as Gleason 7 (3 + 4) recurrent cancer in the right mid-gland

mandatory because of the lack of specificity of no enhancement of CEUS at the end of HIFU
mp-MRI. Random biopsies of areas negative at ablation can be safely considered to have been
mp-MRI are also necessary to detect less aggres- entirely destroyed. On the other hand, prostate
sive Gleason ≤6 tumors that may have been sectors showing any degree of enhancement can
missed by mp-MRI. be considered to contain living (benign or malig-
nant) tissue (Rouvière et al. 2001a) (Fig. 2.6). Postoperative Evaluation These results should lead to immediate re-
of the Ablated Area treatment of the parts of the gland showing
Ideally, imaging should indicate the amount of residual enhancement and that are within the
prostate volume destroyed at the end of the HIFU range of the transducer.
ablation session so that in the event of unsatisfac-
tory results, additional HIFU ablation can be Detection of Post-HIFU Local
immediately performed. Unfortunately, transrec- Recurrences
tal ultrasound, which is used to guide the HIFU After focal HIFU ablation, the residual prostate is
treatment, is not sufficiently accurate to indicate composed of scarred fibrosis and benign prostate
the post-treatment zone of tissue ablation tissue. Given that local recurrences (or residual
(Rouvière et al. 2007). Gadolinium-enhanced cancers) after HIFU ablation can be treated by a
(non-dynamic) MRI clearly reveals the treated second session of HIFU ablation or by radiation
volume as a devascularised zone (corresponding therapy (Rivière et al. 2010), it is imperative that
to the central core of the coagulation necrosis) they be detected early. The precise location of
surrounded by a peripheral rim of enhancement these recurrences can also help in selecting the
(corresponding to oedema). However, MRI can- salvage treatment (e.g., anterior recurrences,
not be obtained in the operating room (Rouvière which are more difficult to treat using HIFU may
et al. 2001; Kirkham et al. 2008). be better treated by radiation therapy or cryother-
Contrast-enhanced ultrasound (CEUS), using apy). Even though Colour Doppler can sensitize
Sonovue™ as a contrast agent, can indicate the transrectal ultrasound (TRUS) (Rouvière et al.
ablated volume immediately at the end of the 2006), US-based techniques are not accurate
treatment with an excellent correlation with MR enough to detect early local recurrences and
and biopsy findings. All prostate sectors showing guide the biopsy.
34 J.-Y. Chapelon et al.

a b

Fig. 2.6 CEUS. Images obtained in a 62-year old patient Ultrasound performed after focal HIFU ablation showed a
referred for focal HIFU ablation of a Gleason 6 PCa of the large devascularized area within the right lobe around the
right mid-gland. The tumor was well visible on tumor area (b, arrowheads)
T2-weighted imaging (a, arrow). Contrast-enhanced

a b

Fig. 2.7 Post-HIFU recurrence. MRI obtained in a gland (b, arrow). This area is difficult to analyze on
70-year old patient with a history of whole-gland HIFU T2-weighted imaging (a, arrow) because the gland
for a Gleason 6 PCa 4 years earlier. MRI indicates early appears as diffusely heterogeneous. Targeted biopsy con-
and marked enhancement in the left base of the residual firmed Gleason 6 recurrent cancer in the left base

MRI, in particularly DCE MRI, seems to pro- recurrence after HIFU ablation performed at our
vide early detection and accurate localization of institution, neither the enhancement pattern nor
recurrent cancers that enhance earlier and more the apparent diffusion coefficient (ADC) was
than post-HIFU fibrosis (Ben Cheikh et al. 2008, able to significantly distinguish BPH nodules
Rouvière et al. 2010) (Fig. 2.7). However, DCE from recurrent cancers. This was even though
MRI lacks specificity. It is indeed difficult to cancer tissues had, on average, higher wash-in
distinguish recurrent cancer from residual benign rates, lower wash-out rates and lower ADCs
prostatic hyperplasia (BPH) tissue. In a retro- (unpublished results). So to date, all patients with
spective study of 65 patients with biochemical rising PSA after HIFU ablation should undergo
2 Prostate Focused Ultrasound Therapy 35

prostate MRI, and all areas with early and intense 95 % were pad-free. Erection sufficient for pene-
enhancement should be biopsied to distinguish trative sex occurred in 95 % of the patients. Mean
cancers from residual BPH tissue. PSA decreased to 1.5 ± 1.3 ng/mL at 12 months. A
total of 89 % of the patients had no histological
evidence of any cancer. Two patients (11.1 %) had
2.5.2 Outcomes of HIFU Focal positive protocol biopsy at 6 months with residual
Therapy 1 mm Gleason 3 + 3: One elected for retreatment
and the other active surveillance. Eighty-nine% Sub-total HIFU Strategy achieved the trifecta status.
In 2008, Muto et al. (2008) reported the outcomes
of 29 patients treated with the Sonablate® device. Zonal Treatment (Belgium
In selected patients whose cancer was confined to Experience)
only one lobe by multi regional biopsies, the total Van Velthoven et al. (2014) reported long-term
peripheral zone and half a portion of the transi- results of 31 patients with unilateral organ-confined
tional zone were ablated. The prostate volume PCa treated by “Zonal” HIFU from January 2007
decreased from 35.8 to 30.3 cc, and the PSA level to June 2011. The biochemical recurrence-free sur-
decreased from 5.36 ± 5.89 ng/mL to 1.52 ± 0.92 vival rate at 3 years was 82.7 % (Phoenix criteria).
at 36 months. Twenty-eight patients underwent All patients were continent and 55 % had erectile
control biopsies 6 months after the procedure: function sufficient for penetration.
Residual cancer foci were found in 3 patients
(10.7 %). Seventeen patients underwent control Hemi-ablation Strategy (French
biopsies 12 months after the procedure: Residual Experience)
cancer foci were found in 4 patients (23.5 %); The French Urological Association (AFU) has
only one patient had urethral stricture. No signifi- started a multi-institutional study to evaluate
cant differences were noted in the 2 years. hemi-ablation with HIFU as a primary treatment
Disease-free survival rates at 2 years for low and for patients >50 years, T1C or T2A, PSA <10 ng/
intermediate risk patients treated with this focal mL, Gleason 6 or 7 (3 + 4), with no more than 2
therapy strategy were 83.3 % and 53.6 %, respec- contiguous biopsies in no more than one lobe
tively. The frequency of urethral stricture and after MRI (random and targeted biopsies). To be
symptomatic tract infection were 4 % and 4 %, included the tumor must be >6 mm from the apex
respectively. No significant change was found on and >5 mm from the midline. Only one prostatic
IPSS score and Maximal Flow Rate before and lobe is treated. Preliminary results are available
12 months after the procedure. No information (AFU Congress 2014, Las Vegas, USA): 110
was provided about potency. patients were treated; mean age 64.8 years {50–
78}, mean PSA value 5.42 ± 3 ng/mL, mean pros- Hemi-Ablation Strategy tate volume 39 ± 17 cc. The Glean sum was ≤ 6 in
(UK Experience) 78 patients (71 %) and = 7 in 32 patients (29 %).
A short series of prostate hemi-ablations with The PSA nadir value was 1.93 ± 1.62 ng/mL and
HIFU using the Sonablate® device was published the PSA at 12 months was 2.42 ± 2.08 ng/mL (78
(Ahmed et al. 2011). Inclusion criteria were men patients). Control biopsies were performed in 91
with low-moderate risk (Gleason = 7, PSA = 15 μg/ patients. Biopsies were negative in 57 patients
mL), unilateral PCa (= T2bN0M0) on TRUS (63 %). Recurrence was found in 34 patients
biopsy. All were treated using transrectal HIFU (37 %): Only in 13 patients in the treated lobe
incorporating the entire positive hemi-prostate up (14 %), 20 patients in the contralateral lobe (22 %)
to the urethra. A total of 20 patients (mean age and 1 patient in both lobes (1 %). The Gleason
60.4 years) were treated. Regarding the cohort, sum of recurrence was 6 (24 patients), 7 (8
25 % had low risk and 75 % had intermediate risk patients) and not determined in 1 patient. The
cancer. The mean PSA pre-HIFU was 7.3 ng/mL. additional therapies were: Redo-HIFU (9
36 J.-Y. Chapelon et al.

patients), active surveillance (18 patients), exter- around the tumor. Contrast-enhanced MRI was
nal beam radiation therapy (4 patients), radical performed at day 2 after HIFU, and control biop-
surgery (4 patients) and AD (1 patient). Grade 1 sies guided with contrast-enhanced ultrasound
incontinence occurred in 2 patients (2 %) and imaging were performed 1 month after HIFU
erectile dysfunction (partial loss of potency with inside and on the edge of the treated area. The
IIEF5 score <17) was observed in 13 patients out mean age of patients was 65.8 ± 5.5 years. The
of 53 patients, with an IIEF5 score ≥17 before clinical stage was T1 for 9 patients and T2a for 1
HIFU (24 %). patient. The Gleason sum was 6 for 7 patients and
7 (3 + 4) for 3 patients. The PSA value was Focal Therapy (Uni- and Multi- 4.47 ± 3.7 ng/mL and the mean Prostate Volume
focal Strategy: UK Experience) was 50 ± 23 cc. The mean treated volume was
(Ahmed et al. 2012b) reported preliminary 14 cc (7.3–20.4) 28 % of prostate gland. The
results from selective focal ablation of single- mean nadir PSA value was 3.46 ± 2 ng/mL. In all
focal and multi-focal cancer in 42 patients (45– patients, targeted biopsies inside the treated area
80 years) eligible for a prospective development performed on day 30 after the HIFU session dem-
study. Eligibility entailed: Low-risk to high-risk onstrated a complete destruction of the targeted
localized PCa, PSA ≤15 ng/mL, Gleason score tumor. No incontinence was observed. A partial
≤4 + 3, stage ≤ T2, no previous AD or PCa treat- loss of potency (IIEF <17) occurred in 2 patients
ment, ability to safely undergo multi-parametric (20 %). The Focal One device is able to achieve
MRI focal therapy using high-intensity focused complete destruction of small PCa using an elas-
ultrasound (HIFU). HIFU was then delivered to tic magnetic resonance-ultrasound (MR-US) reg-
all known cancer lesions, including a margin of istration system for tumor location and HIFU
normal tissue, identified on multi-parametric treatment planning. A multicenter trial is in prog-
MRI template prostate-mapping. No histologi- ress (30 patients).
cal evidence of cancer was identified in 30 of 39
men biopsied at 6 months (77 %); 36 (92 %) Hemi-Salvage HIFU
were free of clinically significant cancer. After for Radio-Recurrent PCa
retreatment in four men, 39 of 41 (95 %) had no Whole gland salvage HIFU treatment offers
evidence of disease on multi-parametric MRI at acceptable cancer control, but carries a risk of
12 months. All 40 men that were pad-free at severe urinary incontinence in at least 20 % of
baseline were still pad-free by 3 months, and cases and reduction of Quality of Life (QoL). In
they maintained pad-free continence at 12 patients with unilateral local relapse, focal HIFU
months. Of the 35 men with good baseline func- is feasible. Two studies reported favourable out-
tion, 31 (89 %, 95 % CI 73–97) had erections comes in selected patients. The results from these
sufficient for penetration 12 months after focal studies indicated that focal salvage therapy is a
therapy. For the authors, this study demonstrated potential strategy for unilateral recurrence after
that focal therapy of individual PCa lesions, radiotherapy that may reduce the side effects
whether multifocal or single-focal, leads to a resulting from whole-gland salvage therapies.
low rate of genitourinary side effects and an
encouraging rate of early absence of clinically UK Pilot Study (Ahmed et al.
significant PCa. 2012a, b)
Thirty-nine patients received focal salvage therapy Focal Therapy (Edouard Herriot for localized recurrence after external beam radio-
Experience) therapy. Multi-parametric magnetic resonance
Ten patients with mono-focal PCa were treated imaging studies, combined with transperineal tem-
between March 2013 and January 2014. The plate prostate mapping biopsies or transrectal
HIFU treatment process was performed with the biopsies, were used to localize disease. Hemi-
Focal One device using a 6 mm safety margin Salvage HIFU (HSH) was performed under spinal
2 Prostate Focused Ultrasound Therapy 37

or general anaesthesia using the Sonablate 500® to those obtained by radiation therapy. HIFU
device. The mean pre-HIFU PSA level was 4.6 ng/ does not represent a therapeutic impasse:
mL. The median follow-up was 17 months. The EBRT is a safe salvage option after HIFU fail-
actuarial progression-free survival rate was 49 % ure and salvage surgery is possible in young
at 2 years according to the Phoenix criteria. Index and motivated patients. On the other hand,
of Erectile Function-5 scores decreased from a HIFU has a considerable potential for local
median of 18 ± 16 to 13 ± 21 at 6 months, demon- recurrence after radiation failure. Recently,
strating worsening deterioration in function. The some early experiences with focal therapy
pad-free, leak-free continence status was 64 %, suggest that HIFU provides an excellent
and the pad-free rate was 87.2 % at last follow-up. opportunity to achieve local control of the dis-
One recto-urethral fistula occurred and spontane- ease in low-risk PCa and in early-identified
ously resolved with urinary and bowel diversion. local relapse after EBRT. Multicenter Study (Baco et al.

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